ObjectiveTo explore the causes of failure to activate the rapid response system (RRS). The organisation has a recognised incidence of staff failing to act when confronted with a deteriorating patient and leading to adverse outcomes.DesignA multi-method study using the following: a point prevalence survey to determine the incidence of abnormal simple bedside observations and activation of the rapid response team by clinical staff; a prospective audit of all patients experiencing a cardiac arrest, unplanned intensive care unit admission or death over an 8-week period; structured interviews of staff to explore cognitive and sociocultural barriers to activating the RRS.SettingSouthern Health is a comprehensive healthcare network with 570 adult in-patient beds across four metropolitan teaching hospitals in the south-eastern sector of Melbourne.MeasurementsFrequency of physiological instability and outcomes within the in-patient hospital population. Qualitative data from staff interviews were thematically coded.ResultsThe incidence of physiological instability in the acute adult population was 4.04%. Nearly half of these patients (42%) did not receive an appropriate clinical response from the staff, despite most (69.2%) recognising their patient met physiological criteria for activating the RRS, and being ‘quite’, or ‘very’ concerned about their patient (75.8%). Structured interviews with 91 staff members identified predominantly sociocultural reasons for failure to activate the RRS.ConclusionsDespite an organisational commitment to the RRS, clinical staff act on local cultural rules within the clinical environment that are usually not explicit. Better understanding of these informal rules may lead to more appropriate activation of the RRS.

Simulation‐based education (SBE) is a rapidly developing method of supplementing and enhancing the clinical education of medical students. Clinical situations are simulated for teaching and learning purposes, creating opportunities for deliberate practice of new skills without involving real patients. Simulation takes many forms, from simple skills training models to computerised full‐body mannequins, so that the needs of learners at each stage of their education can be targeted. Emerging evidence supports the value of simulation as an educational technique; to be effective it needs to be integrated into the curriculum in a way that promotes transfer of the skills learnt to clinical practice. Currently, SBE initiatives in Australia are fragmented and depend on local enthusiasts; Health Workforce Australia is driving initiatives to develop a more coordinated national approach to optimise the benefits of simulation.

Cognitive aids are prompts designed to help users complete a task or series of tasks. They may take the form of posters, flowcharts, checklists, or even mnemonics. It has been suggested that the use of cognitive aids improves performance and patient outcomes during anesthetic emergencies; however, a systematic assessment of the evidence is lacking. The aim of this literature review was to determine (1) whether cognitive aids improve performance of individuals and teams and (2) whether recommendations can be made for future cognitive aid design, testing, and implementation. Medical, nursing, and psychology databases were searched using broad criteria to find cognitive aids that have been reported in the literature for use in anesthetic emergencies. The reference lists of the articles selected for review were also screened to identify additional studies. Selected articles that described the evaluation of cognitive aids used in anesthetic emergencies were reviewed to determine how the content of the aid was derived, how the design was evaluated, and the success of the aid in improving technical and team performance. The search yielded 22 cognitive aids developed to support clinicians during anesthetic emergencies that had been evaluated in 23 studies. Ten studies using simulation suggested that technical performance improves with the use of cognitive aids in some anesthetic emergencies such as malignant hyperthermia, cardiopulmonary resuscitation, and airway management. However, in 3 of the simulator-based evaluations, participants had either no improvement or took longer to diagnose and treat and made more incorrect diagnoses. Four studies investigated the effect of the aids on teamwork with differing conclusions. One study suggested improved participants' coordination patterns and one found aids improved their decision-making scores, but 2 other studies indicated that there was no improvement and even provided evidence of reduced levels of team communication when teams used a cognitive aid in simulated conditions. The designs of cognitive aids were rarely considered. Education may compensate for a poorly designed aid, but only by ingraining correct actions for situations in which the aid provides little or no guidance. Cognitive aids should continue to be developed from established clinical guidelines where guidelines exist. They would also benefit from more extensive simulation-based usability testing before use. Further evidence is required to explore the effects of cognitive aids in anesthetic emergencies, how they affect team function, and their design considerations.

Suspected perioperative allergic reactions are rare but can be life-threatening. The diagnosis is difficult to make in the perioperative setting, but prompt recognition and correct treatment is necessary to ensure a good outcome. A group of 26 international experts in perioperative allergy (anaesthesiologists, allergists, and immunologists) contributed to a modified Delphi consensus process, which covered areas such as differential diagnosis, management during and after anaphylaxis, allergy investigations, and plans for a subsequent anaesthetic. They were asked to rank the appropriateness of statements related to the immediate management of suspected perioperative allergic reactions. Statements were selected to represent areas where there is a lack of consensus in existing guidelines, such as dosing of epinephrine and fluids, the management of impending cardiac arrest, and reactions refractory to standard treatment. The results of the modified Delphi consensus process have been included in the recommendations on the management of suspected perioperative allergic reactions. This paper provides anaesthetists with an overview of relevant knowledge on the immediate and postoperative management of suspected perioperative allergic reactions based on current literature and expert opinion. In addition, it provides practical advice and recommendations in areas where consensus has been lacking in existing guidelines.

The teaching of a structured method of communication improved the communication during telephone referral in a simulated clinical setting. This research has implications for how healthcare professionals are taught to communicate with each other.

The rapid response system (RRS) is a patient safety initiative instituted to enable healthcare professionals to promptly access help when a patient's status deteriorates. Despite patients meeting the criteria, up to one-third of the RRS cases that should be activated are not called, constituting a "missed RRS call". Using a case study approach, 10 focus groups of senior and junior nurses and physicians across four hospitals in Australia were conducted to gain greater insight into the social, professional and cultural factors that mediate the usage of the RRS. Participants' experiences with the RRS were explored from an interprofessional and collective competence perspective. Health professionals' reasons for not activating the RRS included: distinct intraprofessional clinical decision-making pathways; a highly hierarchical pathway in nursing, and a more autonomous pathway in medicine; and interprofessional communication barriers between nursing and medicine when deciding to make and actually making a RRS call. Participants also characterized the RRS as a work-around tool that is utilized when health professionals encounter problematic interprofessional communication. The results can be conceptualized as a form of collective incompetence that have important implications for the design and implementation of interprofessional patient safety initiatives, such as the RRS.

Anaphylaxis is an uncommon but important cause of serious morbidity and even mortality in the perioperative period. The Australian and New Zealand College of Anaesthetists (ANZCA) with the Australian and New Zealand Anaesthetic Allergy Group (ANZAAG) have developed clinical management guidelines that include six crisis management cards. The content of the guidelines and cards is based on published literature and other international guidelines for the management of anaesthesia-related and non-anaesthesia-related anaphylaxis. The evidence is summarised in the associated background paper (Perioperative Anaphylaxis Management Guidelines [2016] www.anzca.edu.au/resources/endorsed-guidelines and www.anzaag.com/Mgmt%20Resources.aspx). These guidelines are intended to apply to anaphylaxis occurring only during the perioperative period. They are not intended to apply to anaphylaxis outside the setting of dedicated monitoring and management by an anaesthetist. In this paper guidelines will be presented along with a brief background to their development.

Suspected perioperative hypersensitivity reactions are rare but contribute significantly to the morbidity and mortality of surgical procedures. Recent publications have highlighted the differences between countries concerning the respective risk of different drugs, and changes in patterns of causal agents and the emergence of new allergens. This review summarises recent information on the epidemiology of perioperative hypersensitivity reactions, with specific consideration of differences between geographic areas for the most frequently involved offending agents.